Health Insurance FAQ ~ Health Insurances

What is Mediclaim (Health) Insurance?

Mediclaim (Health) insurance is insurance coverage for medical treatments. The mediclaim insurance policy is a legal contract between the insured and the insurance company to cover the cost of medical emergencies that are ‘accidental and sudden’. The insured is expected to pay a specific premium amount regularly to utilize coverage benefits. Premiums are fixed not based on one’s income but on an assessment of risk status and coverage benefits. Health insurance policy once issued to a person can be renewed annually or monthly depending upon the insurer and the type of insurance policy chosen.

Who or What is TPA in a Mediclaim policy?

TPA means Third Party Administrator, approved by Insurance Regulatory and development authority (IRDA). They provide service with respect to coordination of treatment in hospitals/settlement of bills on behalf of Insurance Companies. Every Insurance company offers this cashless settlement facility. Even if TPA settles the bill with hospital you may have to submit your bill to TPA with respect to bill for 30 days prior to hospitalization and 60 days to post hospitalization. In your insurance policy the name of the TPA with whom you should coordinate will be clearly mentioned.

What is the difference between several TPAs?

All Third Party Administrator’s (TPA's) are approved by IRDA. There will be differences in the service and the cost for the service charged by the TPA. However all costs are included in the premium being charged from insured.

What are ‘Hospitals’ according to health insurance policies?

'Hospitals' are institutions that are duly registered and actively supervised by a registered medical practitioner, where one can get indoor treatment for sickness and/or injuries. There are few essential criterions to qualify as a ‘Hospital’: they are as follows:

At least 15 beds for patients
Fully equipped operation theatre to conduct surgery
Qualified doctors and
Qualified nursing staff round the clock
What is Domiciliary Hospitalization?
Domiciliary Hospitalization means medical treatment for a period more than three days and an illness/disease/injury which in the normal course would require care and treatment at a Hospital/Nursing Home but actually taken while confined at home under any of the following circumstances, namely:
1. The condition of the patient is such that he/she cannot be removed to the Hospital/Nursing Home or
2. The patient cannot be removed to Hospital/Nursing Home for lack of accommodation therein
4. What is meant by Donor Expenses?
  
  Donor Expenses refers to all hospitalization expenses incurred by the donor for donating an organ (excluding the cost of the organ) to the insured during the course of an organ transplant.
  
  What is Family Floater plan?
  
  Family Floater is one single policy that takes care of the hospitalization expenses of your entire family. Quite often Family floater plans are better than buying separate individual policies. Family Floater plans takes care of all the medical expenses during sudden illness, surgeries and accidents.
  
  e.g.: The Ram Family is covered under a traditional health insurance plan - Mr. Ram Rs. 2 lakh, his wife Rs. 1 lakh, their son and daughter Rs.50,000 each and they have paid premium for all these 4 policies. In an unforeseen situation wherein surgery and post hospitalization bill of their son amounts to Rs. 1.30 lakh. The existing policy will cover only Rs. 50,000, while Mr. Ram will have to bear the balance Rs. 80,000 from his pocket. With Family Health Floater Insurance plan, each member of Ram’s family is covered up to Rs. 4 lakh. Thus, Family Floater would have covered entire Rs. 1.30 lakh medical expenses of Mr. Ram's son.
  
  Why should I take Family Floater health plan if I already have health insurance from my employer?
  
  With your personal insurance plan, you are in control of the insurance coverage. With an employers insurance, there might be limits on the coverage provide. Also, your employer will cover your medical costs as long as you are employed with that company. In the future, you may change your job, retire, or even start your own enterprise, and in these circumstances, you and your family will not be insured, and if a medical emergency arises and you have not arranged for an alternative health insurance policy. Also, purchasing an insurance when you are older and no longer employed is more difficult, as the insurance coverage becomes more restrictive as one ages. Pre-existing conditions are not covered and medical tests are mandatory at older ages, however these tests are not required to purchase medical insurance when you are younger.
  
  Can I utilize family floater plan by declaring my friends as family?
  
  Sorry, family floater is purely for the benefit of your family. Your friends and relatives are not covered under this policy.
  
  What will be the status of our floater cover once it is claimed?
  
  Every time the claim is made by any of the family member covered under the policy, floater cover will reduce to the amount of claim. The original value is restored back next year when you renew the policy.